Secure Intake Form - Hold Me Tight Couples Workshop Questionnaire

Please fill out this questionnaire to express your interest in the workshops. One of our facilitators will contact you to determine whether the workshops are a good fit and will meet your needs.

* = required entry


Demographic Information

* Name:
* Name of Partner

This workshop involves couples working independently on exercises with each other.
* My partner and I are both committed to participating together?  Yes No
Contact Information:

Please provide phone number where we may reach you & leave confidential messages.
* Home #:
Work #:
Cell #:
* Email:
* Full Address:
* How did you find out about this Hold Me Tight workshop?
If it is another professional, please indicate:
Doctor: Therapist: Other:

Workshop Information

* Please indicate which workshop series you'd like to attend:

Fall: October 16th, 23rd, 30th & November 6th, 2021 (4 consecutive Saturdays)
* Can you describe some of your goals in attending this workshop?
* Are there any concerns you have around physical safety or how you may be feeling that you think we should know about?
Yes No
If Yes, please describe your concern:
* Have you recently been working with a couples therapist?  Yes No
If so, who? Phone #
Are they supportive of you attending this workshop?      Yes No
In some cases we find it helpful to speak with your couple's therapist. May we have your permission to do so?  
Yes, my partner and I both consent.

Cancellation Policy:

Should you need to cancel your registration for any reason and are no longer able to attend the workshop, we must receive at least 2 weeks' written notice (this should be done via email) and a refund minus a $50.00 administration fee will be issued. Alternatively, you may choose the option of transferring your registration to VCFI's next HMT workshop at no extra cost. Only the first registration transfer is at no extra cost; any subsequent transfers would be subject to a $50 administration fee which must be submitted at the time of the cancellation email. This will keep your registration active.

If less than 2 weeks' notice is given, unfortunately we can not issue a refund. However you are welcome to transfer your registration to a future HMT workshop at VCFI. The administration fee for this is $50 payable by e-transfer or cheque and in order to keep your registration active we must receive this payment at the time of cancellation.

You can use your transferred registration for any future HMT workshop at VCFI, but please note that whenever you cancel within two weeks, a reactivation fee of $50 will be required again. If you have any questions, you can contact our office at any time and our office administrator will be happy to assist you.

To continue the registration process, please check the box beside the statement below.

* I have read, understand and accept the terms of VCFI's cancellation policy.


* Click below to pay for workshop via VCFI's PayPal account
* Do you want to receive information via email about upcoming VCFI Events or Programs? Yes No